Palolo Chinese Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 2459 10th Avenue, Honolulu, Hawaii 96816
- CMS Provider Number
- 125059
- Inspections on file
- 27
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Palolo Chinese Home during CMS and state inspections, most recent first.
A resident with a recent stroke was admitted for rehabilitation, but staff failed to update the care plan to address stroke-related risks or implement aspiration prevention measures. The resident developed a moist cough and respiratory distress, with staff not recognizing early signs of aspiration, failing to communicate key symptoms to the physician, and not administering ordered treatments. The family ultimately requested hospital transfer after observing the resident's decline, and the resident was admitted in respiratory distress and later placed on hospice.
A resident's medical record contained late entries by nursing staff, resulting in incomplete documentation and failure to communicate important care instructions, such as keeping the head of bed elevated. Additionally, a nurse documented physician notification about the resident's improved respiratory status, but the physician confirmed this communication did not occur.
The facility did not provide residents or their representatives with the grievance official's contact information or inform them of their right to receive written findings of grievance investigations. Additionally, in several reviewed grievances, the facility failed to document investigation findings, conclusions, or corrective actions taken.
The facility did not ensure that contract nursing assistants received adequate abuse prevention training, as required by policy. Review of staff files and agency contracts showed that several contracted CNAs lacked proper documentation or evidence of comprehensive abuse training, and facility leadership relied on agencies to provide this training without verifying its content. This resulted in a failure to protect residents' health, welfare, and rights by not fully implementing abuse prevention policies and procedures.
A nurse in the admissions office accessed a former resident's hospital medical records through an online portal after the resident left the facility AMA and was not expected to return. This access occurred without the resident's consent and after the treatment relationship had ended, violating facility policy and confidentiality agreements.
A resident with multiple chronic conditions reported waking to find someone in her bed who pulled down her undergarment and left. Facility staff did not identify this as potential abuse and failed to notify required authorities, including OHCA, APS, or police, despite policy requiring immediate reporting of such allegations. Staff interviews revealed confusion about reporting responsibilities, and the incident was handled as a grievance rather than a reportable event.
A resident reported waking up to someone lying in bed with her and having her brief pulled down, but the facility did not identify this as potential abuse or report it to the appropriate authorities. The internal investigation was incomplete, missing interviews with the roommate and several staff, lacking a summary of video surveillance findings, and failing to document a clear conclusion. Required investigative steps outlined in facility policy were not followed, resulting in an incomplete response to the allegation.
Two residents experienced delayed staff response to call lights, with wait times ranging from 25 minutes to an hour for assistance with urgent care needs, including incontinence and fall risk. Additionally, a resident with hemiplegia reported that staff did not respect his privacy by failing to knock or close the bathroom door as requested, and made him wait 30 minutes for toileting assistance. The DON acknowledged these lapses and confirmed that not all complaints were formally investigated.
A resident with hemiplegia, hemiparesis, and bilateral amputation, who was cognitively intact, requested a one-arm-drive wheelchair to maintain independence in ADLs and participate in activities. Despite a therapy evaluation supporting this need, the facility did not provide timely follow-up or ensure the resident received the requested wheelchair, limiting his ability to leave his room and participate as desired.
Two residents were not supported in their right to make choices about significant aspects of their daily lives. One resident, who prefers morning oral hygiene, was routinely assisted with brushing teeth much later than desired. Another resident on hospice was left in a wheelchair for extended periods, contrary to family and representative requests for limited time out of bed. The DON confirmed that staff actions did not align with the expressed preferences of these residents.
The facility did not obtain or properly document Advance Health Care Directives (AHCD) for two residents. In one case, there was no documented follow-up with a hospice provider to obtain the AHCD, and in another, a late entry was made after a reminder from leadership, with the resident not recalling recent discussions. Both Social Services staff acknowledged that AHCD documentation should be completed quarterly and entered promptly, but this was not done.
Two residents experienced deficiencies related to environmental cleanliness and protection of personal property. One resident found soiled incontinence items left on her belongings by staff, while another had his personal lamp removed without explanation or documentation of consent. Facility staff did not follow procedures for prompt disposal of soiled items or for communicating and documenting the removal of resident property.
Two residents did not have comprehensive care plans addressing their specific medical needs, including insulin administration for diabetes and oxygen therapy for respiratory care. Despite physician orders and facility policy, the care plans failed to include necessary interventions, as confirmed by record reviews and staff interviews.
A nurse left medications unattended on a resident's bedside table while stepping out of the room to get gloves, making the medications accessible to others. The nurse and DON both acknowledged this was against facility policy, which requires staff to remain with the resident during medication administration and not leave medications in the room without specific orders.
A resident with documented food allergies did not receive the meal he had selected in advance, as the kitchen substituted other items due to his allergies without informing him or offering alternative choices. The resident was confused and dissatisfied when served a meal that did not match his preferences, and staff failed to communicate the reason for the change prior to service.
Two residents requiring modified diets for dysphagia were served meals that did not meet the physician-ordered chopped consistency, with food items observed to be inconsistent in size and not properly prepared. Staff interviews confirmed a lack of clear standards for food preparation, and the facility did not follow established guidelines for chopped diets.
Staff did not check or document the temperature of one kitchen refrigerator during the evening shift for two consecutive days. The temperature log was missing entries and staff initials, and both the EC and DON confirmed that daily temperature checks are required to prevent food spoilage.
Staff failed to properly dispose of a soiled incontinence item by leaving it on a resident's personal belongings, and did not use the required PPE, specifically a gown, while providing direct care to a resident under enhanced barrier precautions for a skin rash. These actions did not follow facility infection control policies and procedures.
A resident with a history of recurrent falls and a recent femur fracture was not accurately assessed for the use of bed and chair alarms as fall prevention interventions. Although staff documented the use of these alarms in progress notes, they were not included in the care plan or reflected in the MDS assessment during the relevant period, resulting in an incomplete assessment of the resident's care needs.
The facility did not update care plans for two residents after significant changes in their conditions. One resident, with a history of falls, suffered a major injury and was readmitted without new fall prevention interventions being added to the care plan, leading to additional falls. Another resident with a urinary catheter did not have catheter care included in the care plan after reinsertion, despite physician orders and facility policy requiring such updates.
Two residents experienced falls with major injuries due to the facility's failure to provide adequate supervision, follow proper transfer protocols, and update care plans with new interventions after significant incidents. One resident was transferred incorrectly by a single CNA unfamiliar with her needs, resulting in a fracture, while another resident with a history of falls did not have new fall prevention measures added to her care plan after a major injury, leading to further falls.
Nursing staff failed to accurately complete fall risk assessments for three residents, resulting in inconsistent and incomplete evaluations following multiple falls, including incidents with major injuries. The DON confirmed that assessments were improperly completed and did not reflect the residents' true risk status, particularly in the areas of gait, balance, and medications.
A resident sustained an unwitnessed fall in the dining room due to the facility's failure to implement care plan interventions. The care plan required supervision of common areas, but a lapse in communication left the resident unsupervised for five minutes after family left, during which the fall occurred. Interviews confirmed the lack of supervision and adherence to the care plan.
Two residents with severe cognitive impairment and high fall risk scores experienced falls due to inadequate supervision. One resident was left unsupervised in the courtyard and sustained a head laceration, while the other fell unwitnessed in the dining room despite care plan instructions for constant supervision in common areas.
A resident with a history of Moyamoya disease and other conditions experienced a delay in care after her spouse reported a limp left arm to a CNA, who failed to notify a nurse. The resident was later diagnosed with a left upper arm fracture. The facility's policy requires staff to report changes to the RN on duty, which was not followed, leading to a delay in treatment.
A facility failed to ensure proper PPE use for a resident under contact precautions. A Radiologist Technologist and a CNA entered the resident's room without wearing gowns, despite a sign indicating contact precautions. The DON confirmed that gowns and gloves should be worn, aligning with the facility's policy to minimize exposure to infectious materials.
Failure to Identify and Intervene in Acute Change of Condition Following Stroke
Penalty
Summary
Facility staff failed to identify and appropriately intervene in an acute change in condition for a resident who had recently suffered multiple strokes and was admitted for rehabilitation. The resident's care plan did not address the recent stroke or include standard interventions for stroke patients, such as elevating the head of the bed to prevent aspiration. Staff did not recognize the resident's occasional moist cough during meals as a potential early sign of aspiration, nor did they communicate this symptom to the physician. Documentation was inconsistent, with conflicting information about the resident's distress when positioned on his back, and the care plan lacked necessary interventions for aspiration prevention. On the evening of admission, the resident developed an increased moist cough and audible congestion, with oxygen saturation dropping to 78%. Staff performed suctioning and notified the physician, who ordered Duoneb and Robitussin for cough and respiratory symptoms. However, staff did not administer these medications as ordered. Progress notes included late entries after the resident was discharged, and there was a lack of timely and accurate communication among staff and with the physician regarding the resident's symptoms and response to interventions. The family was not kept adequately informed of the resident's deteriorating condition and ultimately had to request hospital transfer after observing significant respiratory distress the following morning. Interviews with nursing staff revealed gaps in hand-off communication and a lack of prompt action in response to the resident's low oxygen saturation and persistent symptoms. The physician was not informed that the resident's cough occurred during oral intake, which may have influenced the care plan. The Director of Nursing confirmed that the care plan should have addressed the resident's stroke diagnosis to prevent aspiration. As a result of these deficiencies, the resident was admitted to the hospital in respiratory distress due to aspiration and subsequently placed on hospice care.
Failure to Maintain Accurate and Timely Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and timely documentation in the medical record for one resident, resulting in incomplete records and lack of communication regarding care instructions. Specifically, a registered nurse entered a late progress note into the electronic health record after the resident had already been discharged to the hospital, documenting that the head of bed should remain elevated, but this information was not communicated to staff in a timely manner. Additionally, another nurse wrote a late progress note indicating that a physician had been notified about the resident's decreased coughing and wheezing, but the physician confirmed that this notification did not occur. These late entries led to incomplete and inaccurate documentation of the resident's condition and care provided.
Failure to Provide Grievance Official Information and Written Grievance Outcomes
Penalty
Summary
The facility failed to provide residents and their representatives with the name and contact information of the grievance official, and did not inform them of their right to receive the findings of grievance investigations and conclusions in writing. Policy documents and the admission handbook only referenced oral communication of findings and did not include the required written notification or the grievance official's contact details. During a walkthrough, no posting of the grievance official's name and contact information was observed in the facility. Additionally, review of three resident grievance reports revealed that findings, conclusions, and corrective actions were not documented. In one case, a resident's family reported an incident involving someone entering the resident's bed at night, but the internal investigation summary and follow-up were missing. Another resident complained about staff responsiveness and behavior, but the facility did not document the internal investigation or any actions taken. In a third case, a family member reported concerns about a CNA being too rough, but the investigation summary, corrective action, and communication to the family were not documented in the report.
Failure to Ensure Contract Staff Receive Required Abuse Prevention Training
Penalty
Summary
The facility failed to develop and fully implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility's policy did not address how contract or agency caregivers would receive the required abuse prevention training, except for a brief mention of burnout identification. A review of contract staff files revealed that four out of six contracted nursing assistants lacked evidence of having completed the required abuse prevention training, or the documentation provided was insufficient in content and validation. For example, some training only included minimal or irrelevant content, such as questions about child abuse or intimate partner violence, and others were not properly graded or did not cover all required elements. Interviews with facility leadership, including the ADON, Administrator in Training, CEO, and Human Resource Director, revealed inconsistent practices regarding the orientation and training of contract staff. The ADON admitted to signing off on orientation checklists without directly observing competency demonstrations and stated that only a limited portion of abuse training was provided by the facility, with the expectation that agencies would cover the rest. However, there was no verification that agency-provided training met facility or regulatory requirements. The HRD confirmed that review of agency training content was not part of her process, leaving gaps in oversight. A review of contracts with staffing agencies further demonstrated that most agreements did not specify requirements for abuse prevention training or orientation to facility policies. Some contracts placed the responsibility for orientation and training on the facility, while others were silent on the issue. As a result, there was no assurance that contract staff received adequate training to recognize and prevent abuse, neglect, or exploitation, leading to a deficiency in protecting the health, welfare, and rights of residents.
Unauthorized Access to Former Resident's Medical Records After Discharge
Penalty
Summary
A deficiency occurred when a registered nurse working in the admissions office accessed the external hospital medical records of a resident through an online portal after the resident had left the facility against medical advice (AMA) and with no intention to return. The nurse used the hospital's portal, which is intended for reviewing records of patients being referred or expected to return to the facility, to access the resident's emergency department records the day after the resident's departure. This access was performed without the resident's consent and after the treatment relationship had ended. The resident involved was an older female with a complex medical history, including chronic kidney disease, urinary retention requiring a suprapubic catheter, recurrent urinary tract infections, bladder cancer, and chronic pain. Facility policies, the hospital-facility agreement, and user confidentiality agreements all required that medical records be accessed only for individuals with an authorized treatment relationship and with appropriate consent. The nurse's actions violated these requirements, resulting in a breach of confidentiality and the resident's rights.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a female resident who had recently been discharged from the hospital for acute kidney injury and other chronic conditions. The resident reported that she awoke to find someone lying next to her in bed, who then pulled down her undergarment and left the room quietly. Despite this report, the facility did not identify the incident as potential abuse and did not notify the required external authorities, including the Office of Healthcare Assurance (OHCA), Adult Protective Services (APS), or the police. Interviews with facility staff revealed confusion and a lack of consensus regarding the reporting requirements for such incidents. The Social Services Coordinator stated that nursing was responsible for reporting to the state and social services to APS, but admitted she did not report the incident. The Assistant Director of Nursing (ADON) did not perceive the incident as abuse or a crime, and therefore did not notify authorities, believing the event could have been related to patient care. The ADON also indicated that the incident was not reported because there was no confirmation of abuse or sexual contact at the time. Further, the Administrator in training and the Chief Executive Officer both stated that the incident was handled as a grievance rather than a reportable event. They believed that since the initial investigation did not find evidence of abuse and the sexual allegation was raised after the resident left the facility, it was not their responsibility to report. The facility's own policy, however, required immediate reporting of suspected abuse or sexual assault to law enforcement and state agencies, which was not followed in this case.
Failure to Thoroughly Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident reported by a resident who stated that she woke up with someone lying next to her in bed and that her brief had been pulled down, exposing her. The facility did not identify this incident as potential abuse and did not report the allegation or the results of their internal investigation to the Office of Healthcare Assurance as required. The investigation was led by the Assistant Director of Nursing, who interviewed the resident and reviewed video surveillance, but the documentation of the investigation was incomplete and not in sequential order, with missing times and unclear formats for staff statements. Key investigative steps were omitted, including not interviewing the resident's roommate, who may have had relevant information, and not obtaining statements or interviews from three CNAs and an RN who were assigned to the unit during the period in question. The facility's policy specifically required obtaining statements from roommates when applicable, but this was not done. Additionally, the investigation notes did not include a summary of the findings from the surveillance camera review or correlate these findings with staff statements and interviews. The documentation provided by the facility lacked a clear summary and conclusion of the investigation. Several staff statements were undated or dated several days after the incident, and it was unclear whether they were written or obtained through interviews. The investigation record also did not include a comprehensive assessment of the resident by the nurse, as the lower abdomen and pelvic area were not examined. These omissions resulted in an incomplete investigation and failure to meet regulatory requirements for responding to and documenting alleged violations.
Failure to Ensure Resident Dignity and Timely Response to Care Needs
Penalty
Summary
The facility failed to ensure residents' rights to a dignified existence and timely care, as evidenced by multiple incidents involving delayed staff response to call lights and lack of respect for residents' privacy. One resident reported that staff response to call lights was inconsistent, with a specific incident where a call light was activated for a roommate whose legs were dangling off the bed, and staff took approximately 25 minutes to respond. The resident's representative also described two separate occasions where family members waited 30 minutes to an hour for staff to respond to call lights to address the resident's incontinence needs. The Director of Nursing acknowledged that these response times were excessive and not in line with facility expectations. Another resident, who was cognitively intact and had hemiplegia and hemiparesis following a stroke, reported that staff did not knock or ask permission before entering his room and failed to close his bathroom door as requested, despite signage instructing staff to do so. The resident also stated that a CNA made him wait 30 minutes before assisting with toileting. The Director of Nursing confirmed that not all of the resident's complaints had been formally investigated and agreed that the resident should have been treated with respect and dignity, as outlined in the facility's policy.
Failure to Timely Provide One-Arm-Drive Wheelchair Limits Resident Independence
Penalty
Summary
A male resident with a history of hemiplegia and hemiparesis following a stroke, as well as bilateral amputation, was re-admitted for long-term care. The resident was cognitively intact and expressed a desire to participate in activities outside his room, but reported limited mobility as a barrier. On a specific date, he requested a one-arm-drive wheelchair to enable him to safely and independently perform activities of daily living, including grooming, dressing, and toileting. A physical therapy evaluation documented that the resident required a wheelchair for functional mobility and would achieve maximum independence with a one-arm-drive wheelchair. Despite the resident's request and the therapy recommendation, facility records showed that the request for the specialized wheelchair had not been addressed in a timely manner. The Social Services Coordinator confirmed that the facility was still waiting for an update from the supplier months after the initial request, and the DON acknowledged there was no documentation of timely follow-up. The facility's policy states that residents have the right to participate in social activities at their discretion, but the lack of timely action to accommodate the resident's mobility needs resulted in the deficiency.
Failure to Support Resident Choice in Daily Care and Positioning
Penalty
Summary
The facility failed to honor and support resident self-determination and choice for two residents. One resident, who prefers to brush her teeth three times a day, specifically upon waking and after each meal, reported that staff often delayed assisting her with oral hygiene until late morning or even around lunchtime, despite her preference for morning care. Documentation of oral hygiene tasks confirmed that assistance was most frequently provided in the late morning or afternoon, rather than at the times preferred by the resident. The Director of Nursing acknowledged that the timing of oral care did not align with the resident's stated preferences. Another resident, who is on hospice care and has a weakened physical state, was observed seated in a wheelchair in the dining room for extended periods, including sleeping in the chair, despite family and resident representative requests that the resident not remain in the wheelchair for more than 15-20 minutes at a time. Family members and the resident representative reported that the resident could not tolerate prolonged periods in the wheelchair and had communicated this to staff. Observations and interviews confirmed that the resident was left in the wheelchair for longer than requested, and the Director of Nursing confirmed this was not in accordance with the family's wishes.
Failure to Obtain and Document Advance Health Care Directives
Penalty
Summary
The facility failed to obtain and document Advance Health Care Directives (AHCD) for two residents. For one resident, the electronic health record showed a note indicating that Social Services would follow up with the hospice provider regarding the AHCD, but there was no documentation of any follow-up attempts. The Social Services Coordinator confirmed that no further action was taken to obtain the AHCD and acknowledged that alternative contacts, such as the visiting nurse from the hospice provider, were not pursued. For the second resident, no AHCD was found in the electronic health record, and the Director of Nursing was unable to provide documentation. A late entry was made by the Social Worker, documenting a prior discussion in which the resident refused an AHCD, but this was only entered after a reminder from leadership. The resident recalled an initial discussion about the AHCD upon admission but did not remember any recent conversations. Both the Social Worker and Social Services Coordinator agreed that AHCD documentation should be completed quarterly and entered promptly into the electronic health record, but this was not done in a timely manner.
Failure to Maintain Clean Environment and Protect Resident Property
Penalty
Summary
The facility failed to maintain a clean, homelike environment and did not adequately protect residents' personal property. In one instance, a cognitively intact resident was found with a used incontinence bed pad and used gloves left on top of her personal belongings, including a green bag with arts and crafts supplies and a reusable bowl. The soiled items were not disposed of properly, despite a trash bin being available nearby. The resident reported that she did not place the items there and indicated that agency staff sometimes left dirty items in her room. Facility policy required prompt disposal of soiled linens to minimize odors, but this was not followed. In another case, a cognitively intact male resident reported that his personal floor lamp was removed from his room by maintenance after it broke, but he was not given an explanation or offered a replacement. There was no documentation of his consent for the removal or any explanation provided to him. Interviews with staff revealed confusion about the removal process, and the lamp was later found in the MDS office. The facility did not document the removal or communicate adequately with the resident regarding his property.
Failure to Develop and Implement Comprehensive Care Plans for Insulin and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interview, and record review. For one resident with an order for Insulin Glargine administered via a sliding scale, there was no corresponding care plan addressing the use of insulin. This was confirmed during a review of the resident's electronic health record and through interviews with the Director of Nursing, who acknowledged the absence of a care plan for insulin administration despite the physician's order. Another resident, who was observed receiving oxygen therapy via nasal cannula, also lacked a care plan addressing respiratory care, including oxygen administration. Interviews with an LPN and the Director of Nursing confirmed that the resident's care plan did not include interventions or evaluations related to respiratory care, despite physician orders for oxygen and facility policy requiring such interventions to be documented in the care plan. The resident's diagnoses included vascular dementia and an order for oxygen therapy with specific parameters, but these were not reflected in the care plan.
Medications Left Unattended During Administration
Penalty
Summary
A registered nurse was observed administering medications to a resident and left multiple medications unattended on the resident's bedside table while leaving the room to obtain the correct size glove. During this time, the medications were accessible to anyone who could have entered the room. The nurse acknowledged that medications should not have been left out of sight and recognized the safety concerns associated with this action. The Director of Nursing confirmed that medications should not be left unattended for safety reasons. Review of the facility's Medication Administration policy indicated that staff are required to remain with the resident while medication is swallowed and not to leave medications in a resident's room without specific orders to do so.
Failure to Follow Resident Menu Preferences and Communicate Food Substitutions
Penalty
Summary
The facility failed to ensure that a resident's menu selections and food preferences were followed, resulting in the resident receiving a meal that did not match his advance selections and included items he did not want. The resident, who has documented allergies to pineapple and turkey, had selected beef tomato, rice, and mandarin oranges for lunch, as indicated on his posted menu. However, the kitchen substituted chicken and cauliflower for the selected items without prior communication or explanation to the resident. The substitution was made because the beef tomato contained pineapple, and the alternative entrée, turkey burger, was also not suitable due to the resident's allergy. The resident was not informed of these changes or given the opportunity to choose from other available menu options prior to being served. During the lunch observation, the resident expressed confusion and dissatisfaction with the meal provided, noting that his selected items had been crossed out and replaced without his input. The resident only learned after the fact that the substitution was due to his allergies, and he was not approached beforehand to discuss alternative choices. The lack of communication and failure to follow the resident's documented food preferences led to the resident receiving a meal he did not want, causing confusion and dissatisfaction during the dining experience.
Failure to Provide Physician-Ordered Food Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food in the physician-ordered consistency for two residents who required modified diets due to dysphagia. For one resident, meal observations revealed that food items such as beef, vegetables, tomatoes, and bean sprouts were not chopped to the required size, with some pieces exceeding the defined chopped consistency. Multiple staff members, including Certified Nurse Aides and the Infection Prevention Coordinator, confirmed that the food items did not meet the expected chopped consistency, referencing standards such as 'less than one inch by one inch' or 'sugar cube sized.' For another resident, similar issues were observed, with food items on both lunch and breakfast trays being inconsistent in size and not appropriately chopped. The Executive Chef stated that there was no specific reference size for chopped consistency, despite the IDDSI framework defining bite-sized pieces as no larger than 15 mm. These observations and staff interviews demonstrated that the facility did not consistently prepare food according to the prescribed diet modifications for residents with dysphagia.
Failure to Document Refrigerator Temperatures on Evening Shift
Penalty
Summary
The facility failed to check and document the refrigerator temperature for one of five kitchen refrigerators during the evening shift for two consecutive days. During an initial kitchen walkthrough, it was observed that the temperature log for refrigerator #10 was missing PM temperature readings and staff initials for two specific days. The Executive Chef was unable to explain the omission, suggesting it may have been related to a new system implemented since his start. Both the Executive Chef and the Director of Nursing confirmed in interviews that refrigerator temperatures are required to be checked and recorded every day on both AM and PM shifts to prevent food spoilage.
Failure to Dispose of Soiled Items and Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in two separate incidents. In the first incident, a soiled incontinence bed pad was not discarded appropriately after use; instead, it was placed on a resident's personal belongings and left visible to visitors. According to the facility's policy, such items should be securely wrapped in a plastic bag and discarded as regular trash, and the Infection Preventionist confirmed that leaving dirty items on personal belongings is an infection control concern. In the second incident, a staff member did not use the required personal protective equipment (PPE) while providing direct care to a resident under enhanced barrier precautions (EBP) for a skin rash. The staff member was observed showering the resident while wearing only gloves and a surgical mask, omitting the required gown as indicated by the EBP signage. The resident had a history of a rash with possible diagnoses including dermatitis and shingles, and was under EBP at the time of the observation. The Infection Preventionist and RN confirmed that full PPE, including a gown, should have been used during such care.
Failure to Accurately Document and Assess Use of Bed/Chair Alarms for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's comprehensive assessment accurately reflected the use of bed and chair alarms as interventions for falls. Despite documentation in progress notes and incident reports that staff were utilizing these alarms, the interventions were not included in the resident's care plan until after multiple falls had occurred. Additionally, the quarterly Minimum Data Set (MDS) assessment did not indicate the use of bed or chair alarms, even though progress notes during the assessment period documented their use. The Director of Nursing confirmed that the alarms should have been included in the MDS assessment based on the available documentation. The resident involved had a history of recurrent falls and sustained a left femur fracture requiring surgery following an unwitnessed fall at the facility. After re-admission post-surgery, new interventions were not developed, and the resident experienced two additional unwitnessed falls prior to discharge. The lack of accurate documentation and assessment of the use of bed and chair alarms as fall prevention interventions contributed to an incomplete and inaccurate assessment of the resident's status and care needs.
Failure to Revise Care Plans After Significant Changes in Condition
Penalty
Summary
The facility failed to revise and update the comprehensive person-centered care plans for two residents following significant changes in their conditions. One resident, who had a history of recurrent falls, sustained a major injury—a left femur fracture—after an unwitnessed fall. Upon readmission following surgery, the facility did not develop or document new interventions in the care plan, despite the incident report listing additional measures such as bed in lowest position, fall mat, clip alarm, and bed sensor alarm. The care plan continued to reflect only the standard interventions that were already in place prior to the injury. As a result, the resident experienced two more unwitnessed falls before discharge. The facility's own Fall Prevention Policy required nursing to review and update the care plan after a fall, which was not done in this case. Another resident with an indwelling urinary catheter did not have their care plan revised to include catheter care after the device was reinserted. Although physician orders specified catheter care every shift, and the resident had the catheter for over a month, the care plan was not updated to reflect this need. Both the RN and DON confirmed that the care plan should have been revised to include catheter care, as it is essential for reflecting the resident's current needs and ensuring appropriate interventions. The facility's policy on care plans also required changes to be made as necessary following significant changes in condition or needs, which was not followed.
Failure to Prevent Accidents and Update Care Plans After Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, a cognitively intact female with quadriplegia and contractures, was inappropriately transferred by a single CNA using a manual transfer instead of the required two-person mechanical lift. The CNA was unfamiliar with the resident, did not receive a proper handoff report, and did not check the Kardex for transfer instructions, resulting in the resident falling and sustaining a right ankle fracture. Another resident with a history of repeated falls, dementia, and osteoarthritis was admitted following a fall and fracture. After a subsequent fall with a major injury (left femur fracture), the facility failed to update the care plan with new interventions to address the increased fall risk. Although interventions such as bed in lowest position, fall mat, and alarms were documented in incident reports, these were not consistently included in the care plan or implemented. The resident experienced two additional falls, with documentation showing that interventions like fall mats and alarms were either not in place or not functioning as intended at the time of the incidents. Interviews with the DON confirmed that the care plans were not revised to include new interventions after significant falls, and that interventions listed in incident reports were not always reflected in the care plan or implemented. The lack of proper communication, failure to follow established transfer protocols, and inadequate updating and implementation of fall prevention interventions contributed to the residents' injuries.
Inaccurate Fall Risk Assessments by Nursing Staff
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competency in completing fall risk evaluations for multiple residents. In one case, a resident with a history of falls and a recent major injury (fractured rib) was assessed as high risk for falls prior to and after the incident, but a subsequent evaluation by an RN recorded a significantly lower score, indicating low risk, without justification. The Director of Nursing confirmed that the evaluation was completed improperly and that staff are expected to question such discrepancies. Similar issues were identified for two other residents: one with a history of recurrent falls and a femur fracture, whose fall risk assessment after a third fall was incomplete and scored much lower than previous assessments, and another resident whose post-fall assessment was also incomplete and showed a lower risk score than prior evaluations. These deficiencies were identified through interviews and record reviews, which revealed that fall risk assessments were not completed accurately or thoroughly, particularly in the areas of gait/balance and medications. The improper completion of these assessments placed the affected residents at risk of avoidable adverse outcomes, as their true fall risk status was not accurately reflected in their care plans.
Failure to Implement Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to implement interventions in a care plan for a resident, resulting in the resident sustaining an unwitnessed fall. The resident's electronic health record indicated that the fall occurred in the dining room, and the care plan had specified that common areas should be supervised at all times. However, there was a lapse in supervision when the resident's family left, and staff were attending to other residents, leaving the resident unsupervised for a five-minute window during which the fall occurred. Interviews with the Nurse Manager and a Certified Nurse Assistant confirmed that the resident was left unsupervised, and the care plan interventions were not implemented at the time of the fall. The facility's policy on care plans emphasized the need for staff to implement interventions to achieve care plan goals, but this was not adhered to in this instance. The deficiency highlights a failure in communication and supervision, which are critical components of the resident's care plan aimed at preventing falls.
Inadequate Supervision Leads to Falls in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, both of whom were identified as high risk for falls. The first resident, a male with severe cognitive impairment and a history of spinal stenosis and arthritis, was left unsupervised in the outdoor courtyard by a CNA. During this time, the resident fell and sustained a head laceration. Interviews with staff confirmed that the resident should not have been left unsupervised, especially given his high fall risk score of 13, which indicates a high risk for potential falls. The second resident, a female with severe cognitive impairment due to Alzheimer's disease and other conditions, also experienced a fall. Her fall occurred in the dining room and was unwitnessed, despite her care plan specifying that common areas should be supervised at all times. The resident had a fall risk score of 15, further emphasizing the need for close supervision. Staff interviews corroborated that residents with high fall risk scores require close supervision, which was not adequately provided in this case.
Failure to Report Change in Resident's Condition
Penalty
Summary
The facility failed to ensure timely treatment and care for a resident, identified as R1, who was diagnosed with a fracture of the left upper arm. R1, a female with a medical history including Moyamoya disease, heart failure, and aphasia, was admitted to the facility and later observed by her spouse to have a limp left arm. Despite the spouse reporting this change to a Certified Nurse Aide (CNA1) on 07/10/24, the CNA did not communicate the change to a licensed nurse. The spouse continued to report the limp arm to various staff members until it was finally communicated to a Registered Nurse (RN1) on 07/12/24, who then assessed the resident and confirmed the fracture through an X-ray. The delay in reporting the change in R1's condition resulted in a failure to provide timely care, as the facility's policy requires staff to report any changes in a resident's condition to the RN on duty. Interviews with the CNA1 and the Director of Nursing (DON) confirmed that the CNA should have reported the condition change immediately, allowing for an earlier assessment and intervention. This oversight in communication and adherence to policy potentially affects all residents in the facility, as it highlights a gap in the process of reporting and responding to changes in resident conditions.
Failure to Use PPE for Resident Under Contact Precautions
Penalty
Summary
The facility failed to ensure that staff members, including contracted staff, adhered to the proper use of personal protective equipment (PPE) for a resident under contact precautions. On July 25, 2024, a Radiologist Technologist (RT) was observed in the room of a resident who was under contact precautions due to left ear mastoiditis and left auricular cancer. Despite the presence of a sign indicating contact precautions and instructions for donning and doffing PPE, the RT did not wear a gown while preparing the resident for X-rays. Additionally, a Certified Nurse Aide (CNA) who assisted the RT was also not wearing a gown. The Director of Nursing (DON) confirmed that staff should wear gowns and gloves when entering a room with contact precautions, regardless of the type of care being provided. The facility's policy on contact precautions, dated March 2024, requires staff to wear a gown whenever there is a possibility of direct contact with the resident or potentially contaminated surfaces. The failure to follow these procedures was observed during the interaction with the resident, who was lying in bed while the RT and CNA interacted with them without the appropriate PPE.
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A resident with multiple chronic conditions and documented wandering and exit-seeking behaviors repeatedly expressed a desire to go home and was frequently observed near exit doors, yet her care plan did not address elopement risk despite an elopement risk score above the facility’s threshold. She was taken outside and left alone by an activity aide and later observed alone in an unauthorized outdoor area, and subsequently eloped twice through the unsecured main entrance, being found in the parking lot on both occasions only after another resident alerted staff. The main entrance lacked alarms or automatic locking, there was no reception area to monitor egress, behavior monitoring records did not reflect increased supervision after the incidents, and documentation often indicated no behaviors despite prior notes of exit-seeking.
The facility failed to provide adequate supervision and fall prevention for multiple high‑risk residents, resulting in unwitnessed falls and serious injuries. One resident with a history of repeated unwitnessed falls and documented weakness fell in the bathroom while adjusting clothing and using a FWW, sustaining head abrasions and hematomas; he was discovered by housekeeping staff after calling for help, and an RN later stated he needed more supervision. Another resident with dysphagia, prior falls, and declining mobility attempted to stand from a newly issued wheelchair while a CNA was behind a closed curtain assisting another resident, fell forward onto her face, and suffered a scalp laceration, facial contusions, and facial fractures. A third resident with prior falls and on sedating, hypotension‑associated psychotropic and antidepressant medications was placed in a dining area but left unsupervised when nursing staff were called away; she attempted to ambulate to the bathroom without her walker, fell, and sustained a right hip fracture. Her care plan had not been updated to reflect her current need for consistent walker use, and staff did not fully follow existing interventions regarding walker availability and use.
A resident with debility, legal blindness, CHF, DM, medication side effects, and a history of falls had a care plan identifying fall risk and requiring standby assist with ambulation. Despite this, staff left the resident unsupervised while the RN walked away and the CNA was busy with another resident, and the resident attempted to ambulate without a walker, leading to an unwitnessed fall and hip fracture. The care plan had not been fully updated to reflect the need for consistent walker use, and staff did not fully follow existing interventions related to walker availability and use.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Failure to Supervise and Implement Elopement Interventions for an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision and interventions to prevent accidents, resulting in two elopement incidents involving Resident 36. The resident was an adult female with multiple medical diagnoses including DMII, adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, and obstructive sleep apnea. Review of the electronic health record showed numerous progress notes from October 2025 through January 18, 2026 documenting that the resident frequently verbalized wanting to go home, made frequent phone calls to family, asked staff and other residents to take her home, wandered in the facility, and displayed exit-seeking behavior, including ambulating near the facility entrance and exit doors. Despite these documented behaviors, there was no care plan addressing her wandering and exit-seeking prior to the first elopement on January 19, 2026. On January 19, 2026, the resident eloped through the main exit doors at approximately 6:10 PM. Earlier that day, around 4:00 PM, an activity aide had taken her for a stroll outside and left her alone sitting at a table outside, and later that same day the DON and a Resident Care Manager observed her sitting alone at the resident smoking tent, where she was not allowed to be. The facility’s Elopement Risk Evaluation had been completed on October 16, 2025 with a score of 0 and again on October 28, 2025 with a score of 2, which met the facility’s threshold for being at risk for elopement (score of 1 or greater). However, the Administrator stated that although they review changes in score to determine needed interventions, no interventions regarding the resident’s elopement risk were implemented prior to the January 19 incident. The DON confirmed that the resident had exit-seeking behaviors prior to the first elopement and that she was functionally at supervision level and able to ambulate with a front-wheeled walker. A second elopement occurred on January 28, 2026 at 4:10 PM, nine days after the first incident. For both elopements, the resident was found in the parking lot near the first handicap stall, and staff were not aware she had left the building until another resident notified them. During the survey entrance on March 11, 2026 at 6:45 AM, the surveyor observed that the main entrance doors were unlocked, lacked an alarm or automatic locking mechanism, and opened into a large open area with no reception or receiving area, with no indication that the door could secure automatically to prevent elopement. Review of Behavior Monitoring and Interventions Reports from January 1 to February 28, 2026 showed documentation only once per shift and did not reflect increased monitoring after the two elopements; most entries were marked “No Behaviors Observed,” which was inconsistent with the exit-seeking episodes documented in the progress notes. The facility could not provide documentation of increased monitoring after the first elopement, and at the time of the Administrator’s interview there was still another resident identified as an elopement risk.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an environment free from accident hazards and to provide supervision based on individual residents’ assessed needs. One resident with a history of multiple unwitnessed falls was observed with a bandage on his head and later with visible bruising and abrasions after an unwitnessed bathroom fall. His care plan documented several prior falls, including unwitnessed falls with head pain, bruising, and sliding out of bed while reaching for a urinal. On the date of the most recent fall, he was found on the bathroom floor on his right side with his pants and underwear around his thighs, reporting that he had been attempting to adjust his clothing while walking with a front‑wheeled walker. He sustained multiple abrasions and hematomas to the top and sides of his head, reported 8/10 head pain and nausea, and required transfer to the ER. Nursing staff reported that a housekeeper, not direct care staff, discovered him after hearing him call for help, and the RN stated that the resident needed more supervision, especially given increased weakness since his prior fall. Another resident with dysphagia, a history of falling, and generalized muscle weakness experienced a fall with major injury after attempting to stand from a newly issued wheelchair. She reported that she stood up and did not expect the wheelchair to be so high, lost her balance, and fell forward onto her face while the CNA was in the same room but behind a closed curtain assisting another resident. The resident sustained an approximately two‑inch actively bleeding scalp laceration, facial contusions, and later ER documentation confirmed a closed fracture of the left maxillary sinus, a closed fracture of the left orbital floor, a scalp laceration, and a closed head injury. The MDS showed that, prior to this fall, she had already demonstrated decline in eight of ten mobility areas, and she later returned from the hospital with 8 staples in her scalp and extensive bruising and swelling to the left eye, scalp, and ear. The resident and her family member expressed that the fall should not have happened and attributed it to short staffing. A third resident with a documented fall history and on medications including quetiapine and mirtazapine, both of which have side effects of drowsiness, dizziness, and orthostatic hypotension, sustained an unwitnessed fall resulting in a right hip fracture. She was found on the floor on her right side without shoes, socks, or her walker, and stated she had been trying to go to the bathroom. The care plan had not been updated to fully reflect her current needs for consistent walker use, and staff did not fully adhere to existing interventions regarding walker availability and use at the time of the incident. Nursing staff interviews indicated that this resident required line‑of‑sight supervision and “eyes on her” because she would suddenly stand without warning and was unsteady, yet at the time of the fall she had been placed in the dining area in front of the nurse’s station and was left unsupervised when the RN and CNA were called away. Kitchen staff later found her on the floor, and she reported being on the floor for about 15 minutes before help arrived. She was diagnosed with a right hip fracture, underwent surgery, was admitted to the ICU for hypotension, and subsequently died; the unwitnessed fall with hip fracture was determined to be a contributing event that exacerbated her overall medical decline, though not the primary cause of death.
Failure to Implement Standby Assist and Walker Use Care Plan Resulting in Fall Injury
Penalty
Summary
The facility failed to implement a person-centered intervention for standby assistance with ambulation as outlined in the comprehensive care plan for one resident, resulting in an unwitnessed fall with major injury. The resident had multiple risk factors for falls, including debility, legal blindness, congestive heart failure, diabetes mellitus, medication side effects, and a history of prior falls. The care plan, revised on 01/23/2026, identified the resident as at risk for falls and included an intervention for standby assist with ambulation, updated on 01/22/2026, with a goal that the resident would be free of falls through the review date of 03/25/26. Prior to the incident, the resident had experienced two falls in the facility, one witnessed fall onto the buttocks while fixing clothing by a mirror and one guided fall after losing balance while walking. On 02/06/26, the resident sustained an unwitnessed fall in building 1 on the B unit while attempting unsupervised ambulation without her walker, resulting in a right hip fracture and transfer to the ER for evaluation and surgery. Interviews with nursing staff confirmed that the resident was known to suddenly stand without warning, was unsteady, and required someone present when walking, and that she needed continuous visual supervision due to her fall risk. At the time of the fall, the RN reported having to walk away and the CNA was occupied with another resident, leaving no one available to assist the resident to get up. The final investigation summary noted that the care plan had not been updated to fully reflect the resident’s current needs for consistent walker use and that staff did not fully adhere to existing care plan interventions regarding the availability and use of the walker at the time of the incident.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
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